Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: A case report

Navigating Diagnostic Challenges: Heterotopic Pregnancy Versus Hyperdecidual Reaction in Ectopic Gestation

In the intricate field of obstetrics and gynecology, few scenarios present as complex a diagnostic challenge as the differentiation between heterotopic pregnancy, hyperdecidual reaction, and ectopic pregnancy. These conditions, while distinct, often blur together in clinical presentation, necessitating a nuanced understanding to achieve accurate diagnosis and timely intervention. A heterotopic pregnancy is a rare and potentially life-threatening condition in which a woman simultaneously carries two pregnancies in different locations. One pregnancy is typically located within the uterus (an intrauterine pregnancy), while the other is located outside the uterus, most commonly in one of the fallopian tubes (an ectopic pregnancy). This condition is sometimes referred to as a combined intrauterine and extrauterine pregnancy. The diagnosis of heterotopic pregnancy can be challenging because the symptoms can mimic those of a normal intrauterine pregnancy or an ectopic pregnancy. A combination of clinical symptoms, physical examination, and imaging studies, such as transvaginal ultrasound, can help in the diagnosis. After surgical or medical treatment, close monitoring and follow-up with a healthcare provider are essential. The remaining intrauterine pregnancy will need careful observation to ensure it continues to develop normally. However, in some cases of ectopic pregnancy, there will be hyperdecidual reaction within the uterus, which may sometimes create confusion with intrauterine pregnancy. Here, a case of ectopic pregnancy that was radiologically misdiagnosed as heterotopic pregnancy is presented to highlight the possibility of ectopic pregnancies being misdiagnosed as heterotopic pregnancy due to the hyperdecidual reaction. The index case underwent laparoscopic salpingectomy for tubal ectopic and dilatation and evacuation for suspected failed intrauterine pregnancy. The histopathological report of the intrauterine products of conception confirmed it to be decidua without any trophoblastic tissue.

Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review

PURPOSE

This study aims to share the experience of minimally invasive ultrasound-guided methotrexate intervention in the treatment of heterotopic interstitial pregnancy (HIP) with good pregnancy outcomes, and to review the treatment, pregnancy outcomes, and impact on the future fertility of HIP patients.

METHODS

The paper describes the medical history, clinical manifestations, treatment history, and clinical prognosis of a 31-year-old woman with HIP, and reviews cases of HIP from 1992 to 2021 published in the PubMed database.

RESULTS

The patient was diagnosed with HIP by transvaginal ultrasound (TVUS) at 8 weeks after assisted reproductive technology. The interstitial gestational sac was inactivated by ultrasound-guided methotrexate injection. The intrauterine pregnancy was successfully delivered at 38 weeks of gestation. Twenty-five HIP cases in 24 studies published on PubMed from 1992 to 2021 were reviewed. Combined with our case, there were 26 cases in total. According to these studies, 84.6% (22/26) of these cases were conceived by in vitro fertilization embryo transfer, 57.7% (15/26) had tubal disorders, and 23.1% (6/26) had a history of ectopic pregnancy; 53.8% (14/26) of the patients presented with abdominal pain and 19.2% (5/26) had vaginal bleeding. All cases were confirmed by TVUS. In total, 76.9% (20/26) of intrauterine pregnancies had a good prognosis (surgery vs. ultrasound interventional therapy 1:1). All fetuses were born without abnormalities.

CONCLUSIONS

The diagnosis and treatment of HIP remain challenging. Diagnosis mainly relies on TVUS. Interventional ultrasound therapy and surgery are equally safe and effective. Early treatment of concomitant heterotopic pregnancy is associated with high survival of the intrauterine pregnancy.

Ovarian Pregnancy: 2 Case Reports and a Systematic Review

Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not established. Therefore, all case reports on ovarian pregnancy published in PubMed from November 2011 till November 2022 were reviewed and two case reports were added. In these 84 case reports, 8% of ovarian pregnancies occurred in women without or with blocked oviducts and 23% were localised on the other side than the corpus luteum. Since symptoms are not specific, ovarian pregnancy has to be suspected in all women with abdominal bleeding. Surgical excision is the preferred treatment. However, since an associated intra-uterine pregnancy cannot be excluded, care should be taken not to interrupt this intra-uterine pregnancy with the uterine cannula or by damaging the corpus luteum. In conclusion, in women with abdominal bleeding, an ovarian pregnancy cannot be excluded, even in women with a negative pregnancy test or an empty uterus on transvaginal ultrasonography. Therefore, a laparoscopy is indicated but the surgeon should realise that an associated intra-uterine pregnancy also cannot be excluded and that therefore care should be taken not to interrupt this intra-uterine pregnancy by the uterine cannula or by damaging the corpus luteum.

Should expectant management of heterotopic pregnancy be considered?

KEY MESSAGE

Both expectant and interventional managements are acceptable in selected cases, when heterotopic pregnancy is diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

PURPOSE

Heterotopic pregnancy, though relatively rare, is potentially a life-threatening condition. The aim of the study is to compare expectant versus interventional management of heterotopic pregnancies.

METHODS

This is a retrospective cohort study including all women diagnosed with heterotopic pregnancy on ultrasound from March 2011 to December 2020 in a single medical center. Expectant and interventional management outcomes were compared. Primary outcome was defined as live birth.

RESULTS

Forty-one women were diagnosed with heterotopic pregnancy during the study period. Management was expectant in 10 (24.4%) and interventional in 31 (75.6%) of the women. Expectant management was considered when the patient was stable, and the attending physician decided that the ectopic pregnancy did not continue to develop. Interventions included laparoscopic salpingectomy (n = 26), laparoscopic cornual resection (n = 2), laparotomic cornual resection (n = 1) and gestational sac aspiration (n = 2). The intra-uterine pregnancy continued to develop in 6 (60.0%) and 22 (81.5%) of the women in the expectant and interventional groups, respectively (p = 0.52). All women managed expectantly reached term delivery, as opposed to 17/22 (77.3%) in the intervention management group (p = 0.60). Multivariate analysis found serum β-hCG level as the only independent parameter associated with ongoing pregnancy rate (B = 0.001, p = 0.04).

CONCLUSIONS

Both expectant and interventional management were found to be acceptable when heterotopic pregnancy was diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

First trimester heterotopic pregnancy with shock treated laparoscopically, followed by uneventful term pregnancy and normal birth

Heterotopic pregnancy (HP), a coexistence of intrauterine and ectopic pregnancies, is extremely rare. Although there have been many reports of maternal outcomes in pregnant women with HP, they have not described fetal neurodevelopmental outcomes and survival. A 30-year-old Japanese woman in early gestation who had undergone two previous cesarean deliveries was transferred to our hospital with vital signs of shock. HP was confirmed by ultrasonography and laparoscopic surgery, and right salpingectomy was performed. At term, a 2,875 g neonate was delivered via cesarean section without any complications.

A Case of Heterotopic Ovarian Pregnancy after in vitro Fertilization: Early Diagnosis and Single-port Access Conservative Laparoscopic Treatment

Here, we reported the case of a 32-year-old pregnant woman who presented with sudden abdominal pain at 5 weeks of gestation and diagnosed as ruptured heterotopic ovarian pregnancy. She was conceived after in vitro fertilization. Right ovarian pregnancy was noticed, and we performed right ovarian wedge resection via single-port access laparoscopic surgery. Intrauterine pregnancy had remained intact, and she delivered a term baby. Rapid diagnosis in early gestation and minimally invasive laparoscopy resulted in a satisfactory pregnancy outcome without other complications. Single-port laparoscopic surgery can be feasible and appears to be a good first treatment option in a ruptured heterotopic ovarian pregnancy.

Spontaneous Heterotopic Pregnancy with Unaffected Intrauterine Pregnancy: Systematic Review of Clinical Outcomes

Background and objective: Spontaneous heterotopic pregnancy (SHP) is a rare condition represented by the synchronous coexistence of an intrauterine and an ectopic pregnancy. It rarely occurs with natural conception and is usually a consequence of assisted reproductive techniques. Diagnosis of SHP can be a challenge for the clinician. The evolution of the intrauterine pregnancy is dependent on many factors, such as the location of the heterotopic pregnancy, gestational age at the time of diagnosis, the surgical procedure, the presence of other risk factors, early or delayed management. The aim of this systematic review of the literature was to extract existing evidence on spontaneous heterotopic pregnancy with otherwise unaffected intrauterine pregnancy. Materials and Methods: From a total of 1907 database entries identified in PubMed, EMBASE and Cochrane reviews, we selected 18 papers for narrative synthesis, for which we explored the diagnostic options, treatment, and outcome of these extremely rare epidemiologic occurrences. Manuscripts were assessed using the CARE guidelines for reporting case reports. Results: The main symptom was abdominal pain, and the preferred treatment approach was surgical, more precisely, using a laparoscopic approach. Most cases presented no risk factors, and the diagnosis was mostly made in the first semester. Conclusions: Normal follow-up and evolution of intrauterine pregnancy have been observed regardless of surgical approach (open or laparoscopic). Early diagnosis and treatment are advised, as they impact maternal and fetal outcomes. Evidence on this topic is scarce, predominantly comprised of case reports with variable degrees of adherence to dissemination guidelines. More studies on this topic are required to optimize care protocols for this type of pregnancy.

Rare heterotopic pregnancy after frozen embryo transfer: a case report and literature review

Background

Heterotopic pregnancy occurred after frozen embryo transfer with two D3 embryos, and the case had a history of bilateral salpingectomy due to salpingocyesis. An ectopic heterotopic pregnancy was implanted in the left psoas major muscle, which has not been previously reported.

Case presentation

A 33-year-old woman presented with left back pain after curettage due to foetal arrest in the uterus without vaginal bleeding and spotting, and painkillers relieved the pain initially. When the painkillers ceased to work, the patient returned to the hospital. The β-human chorionic gonadotropin (β-hCG) level remained increased compared with the time of curettage, and a diagnosis of retroperitoneal abdominal pregnancy was suggested by ultrasonography and computerized tomography (CT) with the gestational sac implanted in the left psoas major muscle at the left hilum level. Laparotomy was performed to remove the ectopic pregnancy. During the operation, we carefully separated the adipose tissue between the space of the left kidney door and left psoas major muscle, peeled away the gestational sac that was approximately 50 mm × 40 mm with a 25-mm-long foetal bud, and gave a local injection of 10 mg of methotrexate in the psoas major muscle. Fifty days later, β-hCG decreased to normal levels.

Conclusion

It is necessary to pay more attention to the main complaints to exclude rare types of ectopic pregnancies of the pelvis and abdomen after embryo transfer.